Genital Tract Abnormalities among Female Sex Workers Who Douche with Lemon/Lime Juice in Nigeria

Atiene S. Sagay, Godwin E. Imade, Viola Onwuliri, Daniel Z. Egah, Jonah Musa, Matthew J. Grigg, Tom D. Thacher, James . O. Adisa, Malcolm Potts, Roger V. Short


Vaginal douche products have been associated with cervical cancer. We examined female sex workers (FSWs) in Nigeria who douche with lemon or lime juice and compared the findings with that of nonusers. We obtained Pap smears and performed colposcopy of the vulva, vagina and cervix. A total of 374 FSWs comprising 81 Lemon users (LUs) and 293 non lemon users (NLUs) were examined. Their mean age was 27.8 ± 6.7 (range 16-63) years. At colposcopy, 17(4.5%) had genital warts [LUs 5(6.2%); NLUs 12(4.1%); p=0.43], 61(16.3%) had suspected squamous intraepithelial lesions (SILs) [LUs 17(21.0%); NLUs 44(15.0%); p=0.20] and 65(17.4%) had other findings. Pap smear cytology showed that 87(24.6%) had SILs [LUs 26(33.3%); NLUs 61(22.1%); p=0.03]. Lemon/lime use was associated with cervical dysplasia after controlling for HIV status (Adjusted OR=1.8; 95% CI, 1.0-3.0). Our data suggests an association between the practice of douching with citrus juice and cervical dysplasia (Afr J Reprod Health 2009; 13[1]:37-45).



Les anomalies des voies génitales chez les prostituées qui se douchent en se servant du citron ou du jus de limon au Nigéria. Les produits de la douche vaginale ont été liés au cancer du col.  Nous avons étudié les prostituées au Nigéria qui se douchent en se servant du jus de limon et nous les avons comparées à celles qui ne s’en servent pas.  Nous avons collecté le papanicolaou et nous avons fait la colposcopie de la vulve, du vagin et du col.  Au total, nous avons étudié 374 prostituées qui comprennent 81 qui se servent du citron et 293 qui ne se servent pas du citron.  Leur âge moyen s’est élevé à 27,8 ± 6, 7 (entre 16 et 63 ans).  La colposcopie a montré que 17(4,5%) avaient des verrues génitales [celles qui se servent du citron = 5(6,2%) ; celles qui ne s’en servent pas =

12(4,1%) ; p=0,43], 61(16,3% avaient des lésions intraepitheliales squameuses suspectes (LIS) [celles qui se servent du citron = 17(21,0%) ;  celles qui ne s’en servent pas = 44(15,0%) ; p = 0,20] et 65 (17,4%) avaient d’autres résultats.  La cytologie du papanicolaou a montré que 87(24,6%) avaient LIS [Celles qui servent du citron = 26(33,3%) ; celles qui ne s’en servent pas = 61(22,19%) ; p = 0,03].  L’utilisation du citron/du jus de limon a été liée à la dysplasie cervicale après avoir contrôlé pour l’état du VIH (OR yiste = 1,8 ; 95% CI, 1,0 – 3,0). Nos données indiquent un lien entre la pratique de se doucher avec le jus de limon et la dysplasie cervicale (Afr J Reprod Health 2009; 13[1]:37-45).


KEYWORDS: CIN, Cytology, Douching, Lime, Nigeria 

Full Text:



Wang B, Li X, Stanton B, Yang H, Fang X, Zhao R, Dong B, Zhou Y, Liu W, Liang S. Vaginal douching, condom use and sexually transmitted infections among Chinese female sex workers. Sex Transm Dis, 2005; 32:696702.

Gresenuet G, Kreiss JK, Chapko MK, Hillier SL, Weiss NS. HIV infection and vaginal douching in central Africa. AIDS, 1997; 11:101-6.

Fonck K, Kaul R, Keli F, Bwayo JJ, Ngugi EN, Moses S, Temmerman M. Sexually transmitted infections and vaginal douching in a population of female sex workers in Nairobi, Kenya. Sex Transm Infect, 2001; 77:271-5.

Rustomjee R, Abdool Karim Q, Abdool Karim SS, Laga M, Stein Z. Phase I trial of nonoxynol-9 film among sex workers in South Africa. AIDS, 1999; 13:1511-5.

Nwoha PU. The immobilization of all spermatozoa in vitro by bitter lemon drink and the effect of alkaline pH. Contraception, 1992; 46:537-42.

Clarke GN, McCoombe SG, Short RV. Sperm immobilizing properties of lemon juice. Fertil Steril, 2006; 85:1529-30.

Imade GE, Sagay AS, Onwuliri VA, Egah DZ, Potts M and Short RV. Use of lemon or lime juice douches in women in Jos Nigeria. Sexual Health, 2005; 2: 237-9.

Lackman-Smith C, Snyder B, Luckenbaugh K. In vitro assessment of efficacy and cytotoxicity of natural substances proposed as vaginal microbicides against sexual transmission of HIV. Poster presented at 13th Conference on Retroviruses and Opportunistic Infections, Paper 894, February 6, 2006.

Why women should not use lemon or lime juice as a microbicide. Global Campaign for Microbicides 2006, PATH. http://www.nswp. org/pdf/LEMON-060624.PDF

Short R.V. New ways of preventing HIV infection: thinking simply, simply thinking.

Phil Trans R Soc B, 2006; 361(1469): 811-20

Scholes D, Stergachis A, Ichikawa LE, Heidrich FE, Holmes KK, Stamm WE.

Vaginal douching as a risk factor for cervical Chlamydia trachomatis infection. Obstet Gynecol, 1998; 91:993-7.

Imade G, Sagay A, Egah D, Onwuliri V, Grigg M, Egbodo C, Thacher T, Potts M, and Short, R Prevalence of HIV and other sexually transmissible infections in relation to lemon or lime juice douching among female sex workers in Jos, Nigeria. Sexual Health, 2008; 5: 55–60.

Harry W. Haverkos Multifactorial Etiology of Cervical Cancer: A Hypothesis Med Gen Med, 2005; 7(4): 57.

Boon ME, Suurmeiyer AJH. Papanicolaou Staining Method. In Pap smear, 3rd Edition. Taylor Francis UK. 1998. 257-266.

NCWI. The 1988 Bethesda system for reporting cervical / vaginal cytologic diagnosis. JAMA, 1989; 262: 931-4.

Obafunwa J.O., Sagay A.S., Otubu J.A.M. Prevalence of Cervical Intraepithelial

Neoplasia in Jos, Nigeria. Tropical Journal of Obstetrics and Gynaecology, 1991; 9(2):1617.

Zhang J, Thomas AG, Leybovich E. Vaginal douching and adverse health effects: A metaanalysis. Am J Public Health. 1997; 87:1207–1211.

Scholes D, Daling JR, Stergachis A, Weiss NS, Wang SP, Grayston JT. Vaginal douching as a risk factor for acute pelvic inflammatory disease. Obstet Gynecol. 1993 81(4):601-6.


  • There are currently no refbacks.